Dr. Gene Barnett says the Cleveland Clinic hopes Congress will change its mind and pay the older, higher rates for the tumor-zapping device.-

WASHINGTON -- Some Ohio doctors call the Gamma Knife the “gold standard” for removing or reducing brain tumors. That’s why the Cleveland Clinic has used the noninvasive radiosurgical tool on more than 4,000 patients since 1997, saying its ability to converge more than 200 radiation beams on a single spot has been highly effective for many people with brain cancer or tumors.

“Yes, there are other units that do some type of radiosurgery in the head, but often times they can’t do the full scope as well,” said Dr. Gene Barnett, vice chair of the Clinic’s Department of Neurological Surgery.

The Gamma Knife’s ability to direct cobalt radiation to an area as small as a millimeter makes it well-suited for the precision required of brain radiosurgery, says Dr. Mitch Machtay, chairman of radiation technology at University Hospitals Case Medical Center. Some cancer centers, such as Akron General Hospital and the James Cancer Hospital at Ohio State University, even boast on their websites that they have the only Gamma Knife devices in their individual counties or regions of the state.

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Yet within the worlds of radiology, neurology and federal government, the monetary value of this cancer-fighting technique is in debate. This is more than an academic argument, because starting Monday, April 1, the federal government will cut payments by 58 percent when senior citizens get Gamma Knife treatments.

Pay for Gamma Knife treatments under Medicare will drop from about $8,100 to $3,400, according to the American Association of Neurological Surgeons. The association and Congress of Neurological Surgeons told lawmakers in a joint letter this month that they worry “that patients with brain cancer and other neurological diseases will lose access to this important therapy.”

No one on Capitol Hill, however, appears ready to do anything about it. In fact, an act of Congress is the very reason for the Gamma Knife reimbursement cut. The reduction was thrown into the Jan. 1 “fiscal cliff” legislation that temporarily solved a federal budget problem.

And while some physicians are outraged, others say the change was overdue.

These are doctors who use brain tumor-fighting technologies other than the Gamma Knife, and they say that all that Congress has done is equalize payment rates among competing technologies. They acknowledge that the Gamma Knife over the last two decades changed the way brain tumors, certain blood vessel malformations in the brain and, sometimes, certain types of facial pain are treated. The device is specifically geared to target brain lesions, with the patient’s head attached to a frame to hold it still.

But other technologies have evolved using linear accelerator technology, or what’s known as linac. Rather than utilize highly radioactive cobalt, as the Gamma Knife does, linac machines use technology to accelerate X-ray beams, providing a different form radiation treatment. This can be used on other body parts as well, unlike the brain-specific Gamma Knife. There is no reason, proponents of linac technology say, that Gamma Knife treatments, with the same outcome, deserve more money from Medicare.

Which treatment works best? When it comes to the brain, the Cleveland Clinic and University Hospitals like the Gamma Knife.

“We prefer Gamma Knife for lesions within the brain that can be treated with one single, large radiation fraction,” said Machtay. UH has linear accelerator technology available as well, in the form of yet another machine called the Cyber Knife.

Doctors across the country say the choice often comes down to a physician’s individual preference and familiarity.

“Some physicians are actually trained and feel more comfortable using the Gamma Knife versus linac-based radiosurgery, and vice versa,” said Dr. Arnab Chakravarti, chairman of the radiation oncology department at OSU, where both both technologies also are available. “So part of it is predicated upon a physician’s training and background as to which approach he or she feels more comfortable with.”

In interviews, proponents of each technology boasted of its advantage over the other, citing patient comfort, speed or precision as their yardsticks. Each side pointed to studies validating its effectiveness.

Dr. Kevin Murphy, chief of pediatric oncology services at the University of California at San Diego, said the Gamma Knife was “the original way to do radiosurgeries,” but he considers it “like a ‘67 Mustang.” It was cool, but technology has leapt forward. Murphy acknowledged that he has been a speaker on behalf of Varian Medical Systems, which makes linac machines and lobbied to decrease the Gamma Knife payments from Medicare.

Dr. John Kresl, a radiation oncologist in Phoenix, Arizona, said he has used both technologies and also thinks there is no reason that Medicare should pay more for the Gamma Knife, since the outcome is the same.

“I think, based on the clinical aspect of it, it is very sound reasoning,” he said. “There is absolutely no difference between any of the treatment devices” to treat brain tumors, he said.

Dr. Aaron Spalding, a pediatric radiation oncologist at the Norton Cancer Institute in Louisville, Ky., said that “if your mother came to me or your father came to me and said, ‘I have this condition and it was a condition that can be treated with either of the machines, which one’s the best one for me?’ I’d honestly tell you to flip a coin and say whichever side you pick is going to be a winner because they’re both great. They’re equivalent.”

OSU’s Chakravarti said there are no studies comparing the two over time, “so it’s hard to say definitively that one modality of radiosurgery is better than the other.”

Elekta AB, a Swedish company, makes the Gamma Knife. It has tried to raise attention on Capitol Hill to what it considers an unfair cut in Medicare payments to cancer centers that use its machines, but with little success.

The manner in which the cut for the Gamma Knife was made, however, raised eyebrows initially. According to the Wall Street Journal, Sen. Harry Reid of Nevada, a Democrat and the Senate majority leader, had ties to Varian, which used its influence to get the Senate to require the Centers for Medicare and Medicaid Services to make the payment change.

Reid’s office did not respond to a Plain Dealer request for comment. It dismissed the political implications in January when it suggested to the Journal that the change was made merely to equalize payments between the two technologies.

Varian had tried over several years to get CMS to equalize the payments. It noted that the payment rates had, in fact, been roughly equal until CMS raised them for the Gamma Knife in 2006 -- an act that itself has been described as political. This owes to claims that the late Pennsylvania U.S. Sen. Arlen Specter was so impressed with his Gamma Knife treatment in 1996 that he asked CMS to see if Medicare was paying adequately.

But the International RadioSurgery Association, which worked with Specter on the change, told the Huffington Post that the late senator was not seeking a special provision, and noted that it took years and hard data to convince CMS to raise the Gamma Knife rate.

How the April 1 cut will affect patients remains to unfold, but Ohio hospitals that use the Gamma Knife say they will continue using it for now.

The bigger question, said University Hospitals, is how this will affect decisions in future years, when hospitals make capital upgrades and replace equipment. Not only does this kind of machinery cost $5 million or more, but the radioactive cobalt used in the Gamma Knife must be replaced every five years or so, doctors say, an expensive and environmentally sensitive process. Linac machines do not require this.

Medicare patients account for about half those treated with the Gamma Knife at UH and the Clinic. If a hospital loses $250,000 to $1 million in Medicare reimbursements due to the lower rates, the lost revenue could factor into replacement considerations.

“So in the future, a few years down the line as people are looking at that maintenance and the upgrade, people may decide not to have the Gamma Knife any longer,” said Linda Mangosh, vice president of operations at UH’s Seidman Cancer Center.

Barnett, of the Cleveland Clinic, said, “We’re going to continue to treat people with Gamma Knife who need treatment. That said, we’re working with some other Gamma Knife centers in Ohio to try to get the legislation overturned.”

A spokeswoman for U.S. Sen. Sherrod Brown, an Ohio Democrat, said the issue has not yet raised many ripples on Capitol Hill.

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